Athlete’s Foot

(Tinea pedis)
Loh Xin Hui
03/06/09
Background
 Athlete's foot(tinea pedis) is a fungal infection of the soles of the feet and
the interdigital spaces.
 Thought to be the world’s most common dermatophytosis.
experienced by up to 70% of the population at some time in their lives.
 Trichophyton rubrum, Trichophyton mentagrophytes, and Epidermophyton
floccosum are the most commonly cause tinea pedis, with T.rubrum being
the most common cause worldwide.
 Tinea pedis may lead to an autosensistisation reaction, called
dermatophytid, which is a secondary cutaneous reaction occurs at a site
distant to a primary fungal infection, resulting in tinea manuum (fungal
infection of palms and finger webs), tinea unguium (fungal infection of
nails), or tinea cruris (fungal infection of the groin and pubic region).
Background
 Tinea pedis is contagious, and spreads from
person to person through skin-to-skin contact,
or indirectly through towels, clothes or floors.

 The prevalence increases with age. Mostly

occurs after puberty.

 Adults are more likely than children to get

athlete's foot. And, men get it more often than
women do.
Pathophysiology
 Dermatophyte fungi uses enzymes, called keratinises, to
invade the superficial keratin of the skin, and the infection
remains limited to this layer.
 Dermatophyte cell walls also contain mannans, which can
inhibit the body's immune response.
 Fungi infect the superficial layer of the skin. In response to
this fungal growth, the basal layer of the skin produces
more skin cells than usual.
 As these cells push to the surface, the skin becomes thick
and scaly. Most often, the more the fungi spread, the more
scales produce on the skin, causing the ring of advancing
infection to form.
Risk Factors for Developing Tinea
Pedis
 Prolonged use of closed-in (occlusive)
footwear
 Prolonged exposure to moist, warm
environment
 Excessive sweating (hyperhidrosis)
 Communal bathing
 Contact with infected persons/pets/materials
 Immuno-compromised
 Contact sports
Clinical Features
- It takes about 2 weeks from inoculation to subsequent skin
changes that are clinically visible.
- There are 3 main types of athlete’s foot. Each type has a
different appearance and symptoms, though any two or even
all three types may occur together.

1. Interdigital athlete’s foot

- the most common kind of athlete's foot.
- an infection of the web spaces between the toes, particularly
between the 4th and 5th toes.
- The skin appears moist and waterlogged and is often itchy.
- The dorsal surface of the foot is usually clear, but some
extension onto the plantar surface of foot may occur.
 Clinical Features
2. Moccasin type athlete’s foot (hyperkeratotic type)
- involved the bottoms and sides of the feet and the heels.

- has a dry scaly (flaky) appearance. The skin may be red and the
scale may range from white to silver.
- is rarely itchy or uncomfortable.

- may be accompanied by the presence of co-existing fungal toenail

infection. The toenails may appear thickened and discolored.
- Some people may have a co-existing fungal infection on one of
their hands, so-called “two feet-one hand tinea” syndrome. Thus, it
is important to examine the hands in people with athlete’s foot,
and to treat them as well, if they appear red and scaly.
 Clinical Features
3.Inflammatory (blistering) athlete’s foot
- Red, crusting rash on the soles or sides of the

feet with blisters or pustules, and discoloration

on the sole of the foot.
- can be quite itchy or painful and may become

secondarily infected with bacteria.

Laboratory Studies
 Diagnosis can be done through direct
potassium hydroxide (KOH) staining for
fungal elements.
 A KOH preparation is performed on skin

scrapings from the affected area.

 KOH mixed with a blue-black dye is added

to a sample from the infected tissues. This

mixture makes it easier to see the
dermatophytes or yeast under the
microscope.
 Dermatophytes or yeast seen on a KOH test

indicate the person has a fungal infection.

Treatment
 Medical therapy is the mainstay of treatment.
 Good hygiene plays an important role. It is
very important to keep feet and footwear as
dry as possible.
 Atheletes foot can be treated with either
topical or oral antifungals or a combination of
both.
 Conventional treatment typically involves
application of a topical medication in
conjunction with hygiene measures.
 Topical antifungal agents can take the form of
a spray, powder, cream, or gel.
 Treatment
Options
1.Topical imidazoles
 Work primarily by inhibiting the conversion of
lanosterol to ergosterol. The disruption in the
biosynthesis of ergosterol causes significant damage
to the cell wall of fungi, increasing permeability and
causing cell lysis.
 Excellent treatments for interdigital tinea pedis

because they are effective against dermatophytes

Medication
and Candida. Dosage Duration
Clotrimazole 1% 2-3 times daily 2-4 weeks, continue
cream for another 14 days
after symptoms
resolve.
Miconazole 2% cream 1-2 times daily 1month, continue for
another 10 days after
symptoms resolve.
(Blue Book 2008, Drug Information Handbook 14th Edition)
2. Topical allylamines (terbinafine)

 Inhibiting squalene epoxidases which prevents

conversion of squalene to lanosterol, decreases
ergosterol synthesis, causing death of fungal cells.
 Effective in treating all forms of tinea pedis.
 Potent activity against dermatophyte fungi, so they are
useful in treating patients with refractory tinea pedis
(eg, chronic hyperkeratotic).
 Available as OTC product:
Terbinafine 1% cream (apply to the affected area twice
daily for at least 1 week.)
3. Tolnaftate (antifungal)

- Inihibits growth of dermatophytes. Exact mode of

action is unknown.

- Available as OTC product:

Tolnaftate 1% cream (apply to the affected area
twice
daily, may use up to 4 weeks)
Comparison of efficacy
 Several placebo controlled studies report that good foot
hygiene alone can cure athlete's foot even without
medication in 30-40% of the cases. (Bedinghaus JM. et.al.2001)

 There is evidence that terbinafine is better than the azoles in

preventing recurrence in athelete’s foot. (Blenkinsopp A. et.al. 2004)

 Another study showed that terbinafine cure slightly more

infections than azoles. (Crawford F. et.al. 2007)

 Tolnaftate has been found to be generally slightly less

effective than azoles when used to treat tinea pedis. It is,
however, useful when dealing with ringworm, especially
when passed from pets to humans. (Crawford F. et.al. 2007)
 Practice Points
 Recurrence of the infection is often due to a patient's
discontinuance of medication after symptoms abate. The
recommended course of treatment is to continue to use
the topical treatment for 2-4 weeks after the symptoms
have subsided to ensure that the fungus has been
completely eliminated.

 Moccasin-type tinea pedis is often recalcitrant to topical

antifungals alone, owing to the thickness of the scale on
the plantar surface. The concomitant use of
keratolytics(salicylic acid) with topical antifungals should
improve the response to topical agents.

 Severe or prolonged fungal skin infections may require

treatment with oral antifungal medication.
Oral antifungal
 Should be considered in patients with extensive chronic
hyperkeratotic or inflammatory/vesicular tinea pedis, or
for patients in whom topical treatments have failed or
patients with immunocompromising conditions.
 Length of therapy depends on severity of the condition.
Medication Dosage
Terbinafine 250 mg daily.
Itraconazole 100-400 mg daily.
Fluconazole 200-400 mg daily.
Ketoconazole 200-400 mg daily for 4weeks to 6 months.

Griseofulvin 500-1000 mg
(Bluedaily
Book in single
2008, or divided
Drug Information 14doses.
th
Edition)
In a systematic review, terbinafine was found to be more
effective than griseofulvin, while the efficacy of terbinafine
and itraconazole were similar. (Bell-Syer SE, et al.2002)
Possible Complications
 Athlete’s foot is usually a mild fungal infection, but
occasionally the skin may become inflammed and sore if
macerated and broken.

 Once the skin is broken, bacteria can enter the epidermis

through cracks in the skin, which is more vulnerable to
secondary bacterial skin infection (cellulitis) - particularly
common in diabetic patients, the elderly, and people with
impaired function of the immune system.

 The vast majority of cases are caused by Streptococcus

pyogenes or Staphylococcus aureus, which should be
treated with oral antibiotics.
Possible Complications
 In many cases, cellulitis takes less than a week to
disappear with antibiotic therapy. However, it can take
months to resolve completely in more serious cases and
can result in severe debility or even death if untreated.
 Monotherapy with cloxacillin 500 mg QID for 7-10 days
(to cover staphylococcus and streptococcus infection) is
often sufficient in mild cellulitis.
 In cases where streptococcus pyogenes is confirmed,
oral phenoxymethylpenicillin(Pen V) 500 mg QID for 10
days is used.
 For patients hypersensitivity to penicillin, oral cephalexin
500 mg QID for 7 – 10 days can be given.

(Blue Book 2008, Therapeutic Guidelines: Antibiotic. 2006, Treatment of Cellulitis. UpToDate)
Patient Education
Common practice to prevent athlete's foot infection:

 Carefully drying the feet and spaces between the toes

after bathing
 Apply a drying powder to the feet or shoes daily to
absorb moisture.
 Keep socks dry and change them if they become wet.
 Avoiding occlusive (non-breathable) footwear.
 Wearing sandals or other open footwear when possible.
 Avoid walking barefoot in locker rooms and communal
showers where fungal spores may be found.
 Avoid sharing socks, towels, or shoes with others.
1. Baddour LM. Treatment of Cellulitis. 2007. (UpToDate)
2. Bedinghaus JM, Niedfeldt MW. Over-the-counter Foot Remedies.
American Family Physician. 2001. Available at:
http://www.aafp.org/afp/20010901/791.html
3. Bell-Syer, SE, Hart R. et al. Oral treatments for fungal infections of the skin of the
foot. Cochrane Database Systematic Rev 2002.
4. Blenkinsopp A, Paxton P. Symptoms In The Pharmacy: A Guide To The Management
Of Common Illness. 4th Edition 2004. p.147-153.
5. Blue Book 2008.
6. Cellulitis. Available at: http://en.wikipedia.org/wiki/Cellulitis
7. Crawford F, Hollis S. Topical treatments for fungal infections of the skin and nails of
the foot. (Review). Cochrane Database of Systematic Reviews(3). July 2007.
8. Drug Information Handbook International. 14th Edition. 2006.
9. Goldstein AO, Golstein BG. Dermatophyte(tinea) Infections. Dec 2006. (UpToDate)
10. Robbins CA. Tinea Pedis: Treatment & Medication. Nov 2008. Available at:
http://emedicine.medscape.com/article/1091684-treatment
11.Stoppler M. How to Prevent Athlete’s Foot. July 2007. Available at:
http://www.medicinenet.com/script/main/art.asp?articlekey=55264
12.Therapeutic Guidelines: Antibiotic. 2006(13).